Jewish End of Life Preparedness Checklist

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This is not a legal document! It should be held to confidence by the interested parties. This form should be completed, dated and duplicated. Copies should be given to the next of kin, your local synagogue, the
rabbi, the chevra kaddisha – burial society representative, and stored with other valuable documents. If you are uncertain as to how you wish to engage end of life issues around ethical/and Jewish practice and/or have further questions you may wish to speak with a rabbi.

Email *

Full Name *

Address *

Phone *

Birthdate *

YYYY

Birthplace *

Hebrew Name (if applicable)

Parent(s) English & Jewish Name(s) where applicable

Physician(s) - Name, Phone

Designated Health Care Representative - Name, Phone, E-mail

Who to Contact in Event of Death - Name, Phone, E-mail *

(Additional Contact, if any) Who to Contact in Event of Death - Name, Phone, E-mail

Are you affiliated with a synagogue and/or rabbi? If yes, name & location.

Have you made Pre-Need Arrangements? *

If yes, what Funeral Home?

I own a Burial Plot *

If yes, what cemetery? (Block, Number, etc)

I DO NOT currently have a burial plot and wish to be buried in a Jewish cemetery

My wishes regarding my burial site/ceremony/mausoleum etc.

I am a veteran of the U.S. Military *

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